EMERGENCY IMAGING FINDINGS • SENIOR RESIDENT / SURGEON

Pneumatosis Intestinalis

Gas in the bowel wall can be benign or a marker of transmural ischemia. The decision depends on physiology, examination, lactate, enhancement and associated portal venous gas—not the image alone.

PROTOTYPE REVIEW REQUIRED

The Call

Older patient with acute abdominal pain

CT demonstrates pneumatosis in a segment of small bowel. The clinical exam and laboratory trajectory must determine whether this is incidental or ischemic bowel.

Variable

Pneumatosis is a radiologic finding with a wide differential; peritonitis, shock and ischemic CT features make it dangerous.

Read the Image • Clinical DataACS VISUAL

Pneumatosis intestinalis image from the ACS image archive.

Make the Decision • Commit to a Plan

Pneumatosis Intestinalis

Older patient with acute abdominal pain

CT shows pneumatosis and portal venous gas. Patient has lactate 7, shock and diffuse tenderness. Best next step?

Most bowel is viable after relief of a closed loop but one 20-cm segment is frankly necrotic. Best principle?

A separate stable patient on steroids has incidental pneumatosis, normal lactate and no tenderness. Best approach?

Look for the cause and the viability problem.

The underlying cause determines the next chapter.

Surgical Pearls

Pitfalls

Which combination is most worrisome?